Subdural Hematoma Evacuation
[Acute / subacute / chronic] subdural hematoma, [right / left] [with / without] midline shift
Same
[Craniotomy / Burr hole trephination] for evacuation of [acute / chronic] subdural hematoma
[***, MD/DO]
[Resident/Fellow/PA name]
General endotracheal
Patient presents with [altered mental status / focal neurological deficit / progressive headache / declining GCS] in the setting of [traumatic / spontaneous / anticoagulation-associated] [acute / subacute / chronic] subdural hematoma. CT head demonstrates [X] mm hematoma with [X] mm midline shift and [effacement of sulci / uncal herniation]. [Surgical criteria met: hematoma thickness >10 mm or midline shift >5 mm (Brain Trauma Foundation threshold) / comatose patient (GCS <9) with hematoma <10 mm and shift <5 mm but GCS decrease ≥2 points, ICP >20 mmHg, or fixed/asymmetric pupils.] [Anticoagulation reversed preoperatively with [4-factor PCC + vitamin K / andexanet alfa / idarucizumab / platelet transfusion + DDAVP].] Surgical evacuation indicated. Risks including death, reaccumulation, stroke, and neurological deficit discussed.
[Acute / chronic / mixed] subdural hematoma. [Hyperdense / hypodense / mixed density] on CT. Brain [returned to midline / remained shifted] after evacuation. Underlying cortex [normal / edematous / contused].
The patient was taken emergently to the operating room, positioned supine with head turned to the [contralateral] side and secured in Mayfield pins. The scalp was prepped and draped in sterile fashion.
[For craniotomy:] A large [frontoparietal / temporoparietal] question-mark (reverse question-mark trauma flap) incision was made. Periosteum elevated. A large craniotomy ([10-12] cm diameter) was fashioned. Dura was under tension. The dura was opened in a curvilinear fashion with controlled decompression. [Acute / chronic] subdural hematoma evacuated with suction and irrigation. The hematoma was [liquid / gelatinous / clot]. Cortical surface inspected; [no underlying contusion / contusion at [location]]. Hemostasis achieved with bipolar and Gelfoam. Brain relaxed and pulsatile at closure.
[For burr hole trephination (chronic SDH):] Two burr holes placed frontally and parietally. Dura and outer membrane incised. [Brown-liquefied] chronic hematoma evacuated by irrigation with warm saline. [A subdural drain was placed through the posterior burr hole and tunneled for 48-hour drainage.]
Dura closed [watertight / with onlay patch]. Bone flap replaced and secured with titanium plates. Galea and skin closed. Patient tolerated the procedure well.
None
[Subdural membrane sent to pathology / Hematoma discarded]
[X] mL
[Subdural drain to gravity drainage / ICP monitor placed / None]
Patient taken to neurosurgical ICU in [stable / critical] condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: [Acute / subacute / chronic] subdural hematoma, [right / left], with *** mm midline shift
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Craniotomy / Burr hole trephination] for evacuation of [acute / chronic] subdural hematoma, [right / left]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX presenting with [altered mental status / declining GCS / focal neurological deficit] in the setting of a [traumatic / spontaneous / anticoagulation-associated] [acute / chronic] subdural hematoma. CT head demonstrates *** mm hematoma with *** mm midline shift and sulcal effacement. [Anticoagulation reversed preoperatively.] Emergent surgical evacuation indicated. Risks including death, stroke, reaccumulation, and neurological deficit were discussed with family. Informed consent obtained.
FINDINGS: [Acute / chronic / mixed] subdural hematoma. Consistency: [clot / gelatinous / brown liquid with membranes]. Brain [returned to midline / remained shifted] after evacuation. Underlying cortex [normal / edematous / contused].
DESCRIPTION OF PROCEDURE:
Patient taken emergently to the OR, positioned supine with head turned contralateral and secured in Mayfield pins. Scalp prepped in sterile fashion. [CRANIOTOMY: [Frontoparietal / temporoparietal] question-mark (trauma flap) incision; large [10-12 cm] craniotomy fashioned; dura under tension; opened curvilinear with controlled decompression; [acute / chronic] hematoma evacuated with suction and irrigation; cortex inspected — [no underlying contusion / contusion at ***]; hemostasis with bipolar and Gelfoam; brain relaxed and pulsatile at closure; dura closed watertight; bone flap replaced with titanium plates.] [BURR HOLES (chronic SDH): [1 / 2] burr hole(s) placed [frontally / frontally and parietally]; dura and outer membrane incised; brown liquefied chronic hematoma evacuated by irrigation with warm saline until return clear; [subdural / subgaleal] drain placed through [posterior] burr hole and tunneled for [24 / 48]-hour drainage.] Galea and skin closed in layers. Patient tolerated the procedure well.
ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: [Subdural membrane to pathology / Hematoma discarded]
COMPLICATIONS: None
DRAINS: [Subdural drain to gravity drainage / ICP monitor placed / None]
DISPOSITION: Patient taken to neurosurgical ICU in [stable / critical] condition.
Signed: .ME, .MYDEGREE
.TODAYVariants
Burr hole for chronic SDH
Preferred for thin liquid chronic SDH. Single burr hole is non-inferior to double burr hole in randomized data (shorter OR time, equivalent recurrence). Document number of burr holes, location, warm saline irrigation until clear return, drain placement (subdural or subgaleal), and planned drain duration (24-48 hours — DRAIN TIME 2 trial, Lancet Neurology 2024 showed 24h non-inferior to 48h).
Middle meningeal artery embolization (MMAE) for chronic SDH
Adjunctive MMAE reduces 90-day recurrence from ~11% to ~4% when added to surgical evacuation (EMBOLISE trial, NEJM 2024, n=400). MMAE is also used as standalone treatment for asymptomatic or minimally symptomatic chronic SDH and as a bridge in anticoagulated patients.
Bedside twist drill craniostomy
For liquefied chronic SDH in high-risk patients not tolerating OR. Document bedside procedure, drain placement, and output.
Decompressive craniectomy
For malignant cerebral edema after SDH evacuation. Remove bone flap and store (autologous cranioplasty planned). Document duraplasty with patch, brain relaxation at closure, and flap storage.
Charting Tips
- Document hematoma consistency: acute (clot), subacute (motor oil), chronic (brown liquid, membranes)
- State pre- and post-evacuation brain relaxation
- Note any underlying contusion, cerebral laceration, or bridging vein
- For chronic SDH: document drain placement (subdural vs. subgaleal), drain duration (24h or 48h — both supported by evidence; DRAIN TIME 2 trial showed 24h non-inferior), and hematoma consistency at evacuation
- Document reversal of anticoagulation/antiplatelet preoperatively
- ICP monitor placement if brain edematous at closure
Documentation & Reimbursement Considerations
- Report Subdural Hematoma Evacuation as the primary service when it is the definitive operation performed.
- Subdural drain placement is bundled into the applicable service; do not separately bill drain placement. Document drain size, placement depth, and initial output.
- 90-day global period: CT surveillance, drain removal, and clinic follow-up are bundled. Re-operation for reaccumulation (expected, common) within the global period requires related unplanned return-to-the-operating-room reporting. Related unplanned return-to-the-operating-room reporting does not reset the global period.
- This does not affect the surgical reporting for the burr hole/craniotomy component, but document if MMAE was planned or performed as adjunct therapy.